August 3, 2015

Doubling Down on Support for a Quality Physician Advisor

By Allen Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

As I recently traveled around the country interacting with representatives from various clinical documentation improvement (CDI) programs, I began to notice various patterns. What differentiates successful programs from those that struggle in mediocrity or falter and sometimes disintegrate? One factor in particular: an active and expert physician advisor. 

An uninvolved physician advisor may not break a program, but a quality physician advisor certainly CAN make a program. My three keys to success for any CDI program (in no particular order) are expertly trained CDI staff, physician buy-in, and coder buy-in. Not surprisingly, an active and supportive physician advisor helps to build and support all of these key elements. Considering the potential impacts, my observations regarding CDI programs’ success and the anecdotal correlation with having a quality physician advisor are less of a revelation and more in line with common sense.

Education

A physician advisor’s duties are more varied and complex than you might think. This role encompasses such duties as educating CDI staff regarding appropriate clinical criteria to justify a query as well as providing education for coders regarding problematic clinical concepts at risk for misinterpretation. Perhaps most importantly, the physician advisor functions as a credible and expert educator to other physicians regarding the importance of proper documentation and how specific types of documentation “buzzwords” increase or decrease the reported severity and expected morbidity of their patient population. The physician advisor assists other physicians regarding the appropriate clinical circumstances to make a deliberate decision regarding the reporting of certain key diagnoses.

The physician advisor role doesn’t stop with being an educator, however, as he or she must also be a student. It is critical that the physician advisor remain committed to working with both CDI and coders to learn what the critical documentation issues really are. This includes learning how certain generic diagnostic terms are translated into very low-severity clinical problems when they are captured by coding, as well as what possible diagnostic terms are needed in order to properly capture the clinical truth of the patient population.  

Administrative Escalation

Depending on the corporate culture, a team of expert CDI staff may have little or even zero impact on documentation. As I stated above, physician buy-in is a critical piece of any successful CDI program. It is generally considered best practice to have a proper escalation process in place for situations in which there are patterns of problematic documentation or participation. Problematic documentation comes in two forms: over-documentation and under-documentation. Both are quality, severity, efficiency, and reimbursement issues. Over-documentation would include assigning diagnoses that do not appear to be clinically justified (such listing a diagnosis of acute respiratory failure on every patient who is post-op), while under-documentation includes expressing all patient problems as symptomology. A well-run CDI program should address both of these types of issues, and it is imperative that an escalation process be in place to address areas where problematic patterns are identified by the CDI and coding staff.

As crucial as a proper administrative escalation process is, however, I don’t recommend you put one into place without the use of an active physician advisor. Escalating problematic physician behavior is very different than assigning an health information management (HIM) deficiency for failure to document an operative note or discharge summary within the allotted period of time. A CDI escalation has the potential to shine a negative light on physician practices, and this in turn could backfire on a CDI program if the issues are unfounded. You must have a physician advisor function as the expert clinician in these scenarios in order to adjudicate such issues administratively after any failure at addressing the issue diplomatically with a face-to-face consultation with the physician staff. 

Neither a coder nor a CDI specialist is allowed to outright question a physician’s diagnosis (that’s the exclusive purview of RAC). The most a CDI can really do is query a physician, which might reveal a more specific diagnosis. When confronted with questionable documentation that does not appear to be up to clinical standards of practice, however, a physician advisor can become involved, and he or she is crucial in such a situation, on a peer-to-peer level.

Criteria Inclusion   

After consulting for almost 20 years, one thing has become clear: the more you learn, the more you realize you don’t know anything. What works at one hospital will not necessarily work at another. Culture varies greatly from facility to facility. More interestingly, the acceptance of certain buzzwords, diagnoses, and even how the coding departments view and interpret the coding clinics and assign codes varies greatly as well. When looking at what criteria to include or how assertive you will be with regard to certain query types and the thresholds for making those queries, you need a physician advisor. Trying to determine how to handle an upcoming CC opportunity of persistent a-fib? You need a physician advisor. Struggling with how to differentiate between delirium and encephalopathy? You need a physician advisor. Previously been using IV resuscitation as treatment criteria for septic shock, but have now come to the realization that IVF is not a rescue drug for sepsis? You need a physician advisor.

ICD-10

With the implementation of ICD-10, expect a flurry of confusion and physician query activity. ICD-10 will bring about not only a host of new documentation challenges with regard to the language being used to assign diagnosis codes, but also with regard to being able to appropriately assign procedure codes. The initial implementation is going to require a gatekeeper of sorts who can assist the CDI and coding departments with processing the clinical scenarios in relation to coding, plus help make a determination as to which records can reasonably be allowed to bill out as documented and which records are going to require additional clarification. Such oversight will be crucial to keeping the revenue cycle turning and preventing the CDI specialists and coders from falling into analysis paralysis. Physicians are also going to be at risk for severe query fatigue. Going beyond the growing pains of the ICD-10 transition, continued vigilance in terms of filtering and prioritizing is going to become increasingly important long-term, through the 2015 fiscal year – and this is most certainly going to require the involvement and management of a very active physician advisor.

About the Author

Allen Frady is a consultant with experience in management, implementation, education and clinical practice.  With 20 years in healthcare, he provides his clients assistance in the areas of documentation, program implementation and compliance.  His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.

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